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<div id="t1_2" class="text" style="word-spacing: 7px; font-size: 11px;">PLEASE CO M PLETE THE FO LLO WIN G: </div>
<div id="t2_2" class="text" style="word-spacing: 10px; font-size: 11px;">Date  of Se rvice  Provid e d : _____________________________________ </div>
<div id="t3_2" class="text" style="word-spacing: 13px; font-size: 11px;">Patie nt Nam e : _______________________________________ </div>
<div id="t4_2" class="text" style="word-spacing: 18px; font-size: 11px;">Pt. Date  of Birth: _____________________________________ </div>
<div id="t5_2" class="text" style="word-spacing: 24px; font-size: 11px;">C all Location: ________________________________________ </div>
<div id="t6_2" class="text" style="word-spacing: 9px; font-size: 11px;">Zip  C od e  at C all Location: ___________________________ </div>
<div id="t7_2" class="text" style="word-spacing: 6px; font-size: 11px;">C all DISPATC HED as (Ple a se  circle  one ): </div>
<div id="t8_2" class="text" style="word-spacing: 4px; font-size: 11px;">Em e rg e ncy </div>
<div id="t9_2" class="text" style="word-spacing: 6px; font-size: 11px;">Non-Em e rg e ncy </div>
<div id="t10_2" class="text" style="word-spacing: 7px; font-size: 11px;">Pre -Arrang e d  Transp ort </div>
<div id="t11_2" class="text" style="word-spacing: 5px; font-size: 11px;">Was  the  p atie nt trans p orte d  to the  clos e s t ap p rop riate  facility ? (Ple as e  circle  one ): </div>
<div id="t12_2" class="text" style="word-spacing: 0px; font-size: 11px;">YES </div>
<div id="t13_2" class="text" style="word-spacing: 0px; font-size: 11px;">N O  </div>
<div id="t14_2" class="text" style="word-spacing: 3px; font-size: 11px;">If “N O ” w as  c irc le d, ple as e  e xplain w hy : </div>
<div id="t15_2" class="text" style="word-spacing: 0px; font-size: 11px;">___________________________________________________________________________________________________________ </div>
<div id="t16_2" class="text" style="word-spacing: 9px; font-size: 11px;">Starting  Mile ag e  (FULL O DO METER, includ ing  te nth’s):  ____________________ </div>
<div id="t17_2" class="text" style="word-spacing: 8px; font-size: 11px;">End ing  Mile ag e  (FULL O DO METER, includ ing  te nth’s):   ____________________ </div>
<div id="t18_2" class="text" style="word-spacing: 6px; font-size: 11px;">TO TAL LO ADED MILES (includ ing  te nth’s): </div>
<div id="t19_2" class="text" style="word-spacing: 0px; font-size: 11px;">____________________ </div>
<div id="t20_2" class="text" style="word-spacing: 5px; font-size: 11px;">Se rvice  re nd e re d  b y your ag e ncy (Ple ase  circle  one ):    BLS C are  &amp; Transp ort    ALS C are  &amp; Transp ort    ALS Inte rce p t </div>
<div id="t21_2" class="text" style="word-spacing: 4px; font-size: 11px;">If ALS wa s p rovid e d  b y anothe r ag e ncy, which ag e ncy p rovid e d  the  ALS? </div>
<div id="t22_2" class="text" style="word-spacing: 0px; font-size: 11px;">___________________________________________________________________________________________________________ </div>
<div id="t23_2" class="text" style="word-spacing: 5px; font-size: 11px;">If your ag e ncy p rovid e d  ALS for anothe r transp orting  ag e ncy, which ag e ncy p rovid e d  the  transp ort? </div>
<div id="t24_2" class="text" style="word-spacing: 0px; font-size: 11px;">___________________________________________________________________________________________________________ </div>
<div id="t25_2" class="text" style="word-spacing: 5px; font-size: 11px;">If No Hos pital Fac e  She e t is  O btaine d, Ple as e  Us e  This  Se c tion for Patie nt Ins uranc e  Inform ation </div>
<div id="t26_2" class="text" style="word-spacing: 15px; font-size: 11px;">Patie nt Social Se curity Num b e r: _____________________________________________________________________________ </div>
<div id="t27_2" class="text" style="word-spacing: 28px; font-size: 11px;">Nam e  of Insurance : ________________________________________________________________________________________ </div>
<div id="t28_2" class="text" style="word-spacing: 9px; font-size: 11px;">Nam e  of the  Insure d  Party (If d iffe re nt than the  p atie nt): _______________________________________________________ </div>
<div id="t29_2" class="text" style="word-spacing: 23px; font-size: 11px;">Insurance  ID Num b e r: ______________________________________________________________________________________ </div>
<div id="t30_2" class="text" style="word-spacing: 11px; font-size: 11px;">Me d icare  # : ________________________________ </div>
<div id="t31_2" class="text" style="word-spacing: 11px; font-size: 11px;">Me d icaid  # : _________________________________ </div>
<div id="t32_2" class="text" style="word-spacing: 7px; font-size: 11px;">Is this a No-Fault (MVA) claim ? (Ple ase  circle  one ) </div>
<div id="t33_2" class="text" style="word-spacing: 0px; font-size: 11px;">YES </div>
<div id="t34_2" class="text" style="word-spacing: 0px; font-size: 11px;">NO  </div>
<div id="t35_2" class="text" style="word-spacing: 6px; font-size: 11px;">Is this a W orkm an’s C om p e nsation claim ? (Ple ase  circle  on) </div>
<div id="t36_2" class="text" style="word-spacing: 0px; font-size: 11px;">YES </div>
<div id="t37_2" class="text" style="word-spacing: 0px; font-size: 11px;">NO  </div>


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